Factors influencing the one-year mortality of dilated cardiomyopathy

Prognostic Significance of Hemodynamics in Patients With Transposition of the Great Arteries and Systemic Right Ventricle

BACKGROUND

Patients with transposition of the great arteries (TGA) and systemic right ventricle often confront significant adverse cardiac events. The prognostic significance of invasive hemodynamic parameters in this context remains uncertain. Our hypothesis is that the aortic pulsatility index and hemodynamic profiling utilizing invasive measures provide prognostic insights for patients with TGA and a systemic right ventricle.

METHODS

This retrospective multicenter cohort study encompasses adults with TGA and a systemic right ventricle who underwent cardiac catheterization. Data collection, spanning from 1994 to 2020, encompasses clinical and hemodynamic parameters, including measured and calculated values such as pulmonary capillary wedge pressure, aortic pulsatility index, and cardiac index. Pulmonary capillary wedge pressure and cardiac index values were used to establish 4 distinct hemodynamic profiles. A pulmonary capillary wedge pressure of ≥15 mm Hg indicated congestion, termed wet, while a cardiac index <2.2 L/min per m2 signified inadequate perfusion, labeled cold. The primary outcome comprised a composite of all-cause death, heart transplantation, or the requirement for mechanical circulatory support.

RESULTS

Of 1721 patients with TGA, 242 individuals with available invasive hemodynamic data were included. The median follow-up duration after cardiac catheterization was 11.4 (interquartile range, 7.5-15.9) years, with a mean age of 38.5±10.8 years at the time of cardiac catheterization. Among hemodynamic parameters, an aortic pulsatility index <1.5 emerged as a robust predictor of the primary outcome, with adjusted hazard ratios of 5.90 (95% CI, 3.01-11.62; P<0.001). Among the identified 4 hemodynamic profiles, the cold/wet profile was associated with the highest risk for the primary outcome, with an adjusted hazard ratio of 3.83 (95% CI, 1.63-9.02; P<0.001).

CONCLUSIONS

A low aortic pulsatility index (<1.5) and the cold/wet hemodynamic profile are linked with an elevated risk of adverse long-term cardiac outcomes in patients with TGA and systemic right ventricle.

PREDICT HF: Risk stratification in advanced heart failure using novel hemodynamic parameters

BACKGROUND

Invasive hemodynamics are fundamental in assessing patients with advanced heart failure (HF). Several novel hemodynamic parameters have been studied; however, the relative prognostic potential remains ill-defined.

HYPOTHESIS

Advanced hemodynamic parameters provide additional prognostication beyond the standard hemodynamic assessment.

METHODS

Patients from the PRognostic Evaluation During Invasive CaTheterization for Heart Failure (PREDICT-HF) registry who underwent right heart catheterization (RHC) were included in the analysis. The primary endpoint was survival to orthotopic heart transplant (OHT) or durable left ventricular assist device (LVAD), or death within 6 months of RHC.

RESULTS

Of 846 patients included, 176 (21%) met the primary endpoint. In a multivariate model that included traditional hemodynamic variables, pulmonary capillary wedge pressure (PCWP) (OR: 1.10, 1.04-1.15, p < .001), and cardiac index (CI) (OR: 0.86, 0.81-0.92, p < .001) were shown to be predictive of adverse outcomes. In a separate multivariate model that incorporated advanced hemodynamic parameters, cardiac power output (CPO) (OR: 0.76, 0.71-0.83, p < .001), aortic pulsatility index (API) (OR: 0.94, 0.91-0.96, p < .001), and pulmonary artery pulsatility index (OR: 1.02, 1.00-1.03, p .027) were all significantly associated with the primary outcome. Positively concordant API and CPO afforded the best freedom from the endpoint (94.7%), whilst negatively concordant API and CPO had the worst freedom from the endpoint (61.5%, p < .001). Those with discordant API and CPO had similar freedom from the endpoint.

CONCLUSION

The advanced hemodynamic parameters API and CPO are independently associated with death or the need for OHT or LVAD within 6 months. Further prospective studies are needed to validate these parameters and elucidate their role in patients with advanced HF.

Implication of Right Atrial Pressure Estimated by Echocardiography in Patients with Severe Tricuspid Regurgitation

BACKGROUND

Little is known about how tightly right atrial pressure (RAP) is associated with prognosis in patients with severe tricuspid regurgitation (TR). The aim of this study was to investigate the association of RAP estimated by echocardiography (RAP-echo) with cardiovascular events in patients with severe TR.

METHODS

Two hundred forty outpatients (median age, 75 years; 130 women) who underwent two-dimensional transthoracic echocardiography and were diagnosed with severe TR were retrospectively studied. According to RAP-echo using the diameter of the inferior vena cava and its response to a sniff, patients were classified into two groups: low or middle and high RAP-echo. Cardiovascular events were defined as cardiovascular death and admission for heart failure.

RESULTS

During follow-up (median, 428 days; range, 87-1,229 days), 64 patients experienced cardiovascular events. By multivariate analysis, high RAP-echo was independently associated with cardiovascular events (hazard ratio, 2.46; 95% CI, 1.17-5.18). Also, jugular venous distention and leg edema were not independently associated with cardiovascular events.

CONCLUSIONS

The significant and stronger association of RAP-echo with clinical outcome compared with estimates of RAP on physical examination suggests that recognition of high RAP-echo can be a valuable surrogate for the clinical management of severe TR patients.

Altered Aortic Hemodynamics and Relative Pressure in Patients with Dilated Cardiomyopathy

Ventricular-vascular interaction is central in the adaptation to cardiovascular disease. However, cardiomyopathy patients are predominantly monitored using cardiac biomarkers. The aim of this study is therefore to explore aortic function in dilated cardiomyopathy (DCM). Fourteen idiopathic DCM patients and 16 controls underwent cardiac magnetic resonance imaging, with aortic relative pressure derived using physics-based image processing and a virtual cohort utilized to assess the impact of cardiovascular properties on aortic behaviour. Subjects with reduced left ventricular systolic function had significantly reduced aortic relative pressure, increased aortic stiffness, and significantly delayed time-to-pressure peak duration. From the virtual cohort, aortic stiffness and aortic volumetric size were identified as key determinants of aortic relative pressure. As such, this study shows how advanced flow imaging and aortic hemodynamic evaluation could provide novel insights into the manifestation of DCM, with signs of both altered aortic structure and function derived in DCM using our proposed imaging protocol.

Atrial fibrillation in patients with systolic heart failure: pathophysiology mechanisms and management

Heart failure (HF) and atrial fibrillation (AF) demonstrate a constantly increasing prevalence during the 21^st century worldwide, as a result of the aging population and the successful interventions of the clinical practice in the deterioration of adverse cardiovascular outcomes. HF and AF share common risk factors and pathophysiological mechanisms, creating the base of a constant interrelation. AF impairs systolic and diastolic function, resulting in the increasing incidence of HF, whereas the structural and neurohormonal changes in HF with preserved or reduced ejection fraction increase the possibility of the AF development. The temporal relationship of the development of either condition affects the diagnostic algorithms, the prognosis and the ideal therapeutic strategy that leads to euvolaemia, management of non-cardiovascular comorbidities, control of heart rate or restoration of sinus rate, ventricular synchronization, prevention of sudden death, stroke, embolism, or major bleeding and maintenance of a sustainable quality of life. The indicated treatment for the concomitant HF and AF includes rate or/and rhythm control as well as thromboembolism prophylaxis, while the progress in the understanding of their pathophysiological interdependence and the introduction of the genetic profiling, create new paths in the diagnosis, the prognosis and the prevention of these diseases.

Prognostic Value of Pulmonary Transit Time by Cardiac Magnetic Resonance on Mortality and Heart Failure Hospitalization in Patients With Advanced Heart Failure and Reduced Ejection Fraction

BACKGROUND

Pulmonary transit time (PTT) from first-pass perfusion imaging is a novel parameter to evaluate hemodynamic congestion by cardiac magnetic resonance (cMR). We sought to evaluate the additional prognostic value of PTT in heart failure with reduced ejection fraction over other well-validated predictors of risk including the Meta-Analysis Global Group in Chronic Heart Failure risk score and ischemic cause.

METHODS

We prospectively followed 410 patients with chronic heart failure with reduced ejection fraction (61±13 years, left ventricular (LV) ejection fraction 24±7%) who underwent a clinical cMR to assess the prognostic value of PTT for a primary endpoint of overall mortality and secondary composite endpoint of cardiovascular death and heart failure hospitalization. Normal reference values of PTT were evaluated in a population of 40 asymptomatic volunteers free of cardiovascular disease. Results PTT was significantly increased in patients with heart failure with reduced ejection fraction as compared to controls (9±6 beats and 7±2 beats, respectively, P<0.001), and correlated not only with New York Heart Association class, cMR-LV and cMR-right ventricular (RV) volumes, cMR-RV and cMR-LV ejection fraction, and feature tracking global longitudinal strain, but also with cardiac output. Over 6-year median follow-up, 182 patients died and 200 reached the secondary endpoint. By multivariate Cox analysis, PTT was an independent and significant predictor of both endpoints after adjustment for Meta-Analysis Global Group in Chronic Heart Failure risk score and ischemic cause. Importantly in multivariable analysis, PTT in beats had significantly higher additional prognostic value to predict not only overall mortality (χ² to improve, 12.3; hazard ratio, 1.35 [95% CI, 1.16-1.58]; P<0.001) but also the secondary composite endpoints (χ² to improve=20.1; hazard ratio, 1.23 [95% CI, 1.21-1.60]; P<0.001) than cMR-LV ejection fraction, cMR-RV ejection fraction, LV-feature tracking global longitudinal strain, or RV-feature tracking global longitudinal strain. Importantly, PTT was independent and complementary to both pulmonary artery pressure and reduced RV ejection fraction<42% to predict overall mortality and secondary combined endpoints.

CONCLUSIONS

Despite limitations in temporal resolution, PTT derived from first-pass perfusion imaging provides higher and independent prognostic information in heart failure with reduced ejection fraction than clinical and other cMR parameters, including LV and RV ejection fraction or feature tracking global longitudinal strain. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03969394.

Evaluation and treatment of premature ventricular contractions in heart failure with reduced ejection fraction

Premature ventricular complexes (PVCs) are often observed in patients presenting with heart failure with a reduced ejection fraction (HFrEF). PVCs may in some patients be considered to be the cause of heart failure, while in others it may be the consequence of heart failure. PVCs are important prognostic markers in HFrEF. The uncertainty whether PVCs are the cause or effect in HFrEF impacts clinical decision making. In this review, we discuss the complexity of the cause-effect relationship between PVCs and HFrEF. We demonstrate a workflow with the use of a trial period of amiodarone that may discover whether the reduced LVEF is reversible, the symptoms are due to PVCs and whether biventricular pacing can be increased by the reduction of PVCs. The use of non-invasive and invasive (high-density) mapping techniques may help to improve accuracy and efficacy in the treatment of PVC, which will be demonstrated. With these results in mind, we conclude this review highlighting the future directions for PVC research and treatment.

In-hospital ventricular arrhythmia in heart failure patients: 7 year follow-up of the multi-centric HEARTS registry

Aims

The aim of this study was to determine the incidence, predictors, and short‐term and long‐term outcomes associated with in‐hospital sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) collectively termed ventricular arrhythmia (VA) in the heart failure (HF) patients.

Methods and results

The HEart function Assessment Registry Trial in Saudi Arabia (HEARTS registry) is a prospective national registry of patients with chronic HF from18 tertiary care hospitals across Saudi Arabia. Diagnosis of HF was in accordance with American Heart Association/European Society of Cardiology definition criteria. The registry had enrolled 2610 HF patients during the 14 month recruitment period between October 2009 and December 2010. Occurrence of in‐hospital cardiac events, prognosis, and outcome were monitored during the 7 year follow‐up period. The incidence of in‐hospital VA in HF was 4.2%. VA was more common among men, and mean age was lesser than non‐VA patients (58.5 ± 16: 61.5 ± 15 years; P = 0.042). Smoking and family history of cardiomyopathy were significant risk factors of VA. Previous history of arrhythmia, ST elevated myocardial infarction, infections, and hypotension remained significant predictors of in‐hospital VA associated with three to seven times more risk. Patients with VA had higher rates of in‐hospital events like recurrent HF, haemodialysis, shock, sepsis, major bleeding, intra‐aortic balloon pump, and stroke compared with those without VA, all being highly significant (P < 0.001). After adjustment for age, gender, and co‐morbidities, in‐hospital VA increased the risk of cardiogenic shock by 24 times, dialysis and major bleeding by 10 times, and recurrent congestive HF and pacing by five times. Survival analysis showed that all‐cause mortality was significantly higher in the VA patients (P < 0.001). Presence of VA increased in‐hospital and 1 month mortality to 23 and 17 times, respectively.

Conclusions

Lower mean age of VA complicated HF patients is a matter of concern in the Saudi population. HF associated with VA increased in‐hospital events and all‐cause mortality indicating poor prognosis and survival. These findings enable risk stratification and reflect on the importance of early recognition of the clinical markers and predictors of VA prompting immediate management.

Pathophysiologic and Prognostic Implications of Right Atrial Hypertension in Adults With Tetralogy of Fallot

Background Right atrial pressure (RAP), a composite metric of right ventricular diastolic function, volume status, and right heart compliance, is a predictor of mortality in patients with heart failure due to acquired heart disease. Because patients with tetralogy of Fallot (TOF) might have abnormal right atrial and ventricular mechanics caused by myocardial injury and remodeling, we hypothesized that RAP would be associated with disease severity and cardiovascular adverse events in this population. Methods and Results We performed a cohort study of adults with TOF who underwent right heart catheterization at the Mayo Clinic Rochester between 1990 and 2017. The objective was to determine the association between RAP and multiple domains of disease severity in TOF (percentage of predicted peak oxygen consumption, atrial or ventricular arrhythmia, and heart failure hospitalization), as well as cardiovascular adverse events, defined as sustained ventricular tachycardia, resuscitated or aborted sudden death, heart transplantation, or death. Among 225 patients (113 male; mean age: 39±14 years), mean RAP was 10.7±5.2 mm Hg and median was 10 mm Hg (interquartile range: 7-13 mm Hg). Increasing RAP was associated with atrial or ventricular arrhythmias (odds ratio: 5.01; 95% CI, 1.22-23.49; P<0.001), heart failure hospitalization (odds ratio: 1.47; 95% CI, 1.10-2.39; P=0.033) per 5 mm Hg, and worsening exercise capacity (peak oxygen consumption; R2=0.74, r=-0.86, P<0.001). RAP was a predictor of cardiovascular adverse events (hazard ratio: 1.28; 95% CI, 1.10-1.47; P=0.028) per 5 mm Hg. Conclusions In symptomatic patients with TOF, increasing RAP correlates with multiple domains of disease severity (risk stratification) and predicts future cardiovascular events (prognostication). These data have potential clinical implications in the target population of symptomatic TOF patients.

Association between changes in the intrathoracic impedance and ventricular arrhythmias in patients with heart failure

BACKGROUND

Ventricular arrhythmias (VAs) are independently related to mortality risk in patients with heart failure (HF). The wide availability of implantable cardioverter defibrillators and cardiac resynchronization therapy devices now offers an opportunity to clinically correlate the two disease processes. We hypothesized that there is an association between changes in the intrathoracic impedance and episodes of VA.

METHODS

Nonconcurrent prospective study of adults (age >20 years) with known HF with reduced ejection fraction (<35%). The OptiVol threshold was categorized as follows: 0-30 Ω-days, 31-60 Ω-days, 61-90 Ω-days, 91-120 Ω-days, and >120 Ω-days. Patients with OptiVol values at 0-30 Ω-days were used as the reference group. Receiver operating characteristic analysis was used to estimate the sensitivity and specificity at each threshold.

RESULTS

Of the 87 eligible patients, 65.5% were males. The mean age of the sample was 73.3 years (±12.7). Compared to patients in the 0-30 Ω-days category, those in the 31-60, 61-90, 91-120, and >120 Ω-days groups had, on average, 1.48, 1.64, 2.24, and 1.6 more VAs, respectively (P = 0.002, 0.009, 0.010 and 0.009, respectively). The sensitivity and specificity of each threshold were as follows: 82.6% and 61.7% at 31-60 Ω-days, 43.5% and 78.3% at 61-90 Ω-days, 30.4% and 85.0% at 91-120 Ω-days, and 21.7% and 88.3% at >121 Ω-days.

CONCLUSION

Our study found a significant positive relationship between changes in intrathoracic impedance and episodes of VAs in patients with HF.

High central venous pressure is associated with acute kidney injury and mortality in patients underwent cardiopulmonary bypass surgery

PURPOSE

We sought to investigate the relationship between high CVP, AKI, and mortality in patients undergoing cardiac surgery with cardiopulmonary bypass.

MATERIALS

All patients aged 18 years or older who underwent cardiac surgery with CPB were prospectively reviewed. Patients were excluded when renal artery were involved before and during surgery. Patients were dichotomized into high CVP group(>10 mmHg) and low CVP group(<10 mmHg). All patients were followed by telephone.

RESULTS

A total of 1941 patients were included in observed study. In high CVP group, three hundred forty-seven patients (43.32%) developed AKI, while eighty-six (7.543%) in low CVP group(P <0.0001). Furthermore, in every KDIGO stage, patients of AKI in high CVP group were more than those in low CVP group(P <0.0001). The incidence of AKI increased as CVP increased, especially when CVP was higher than 10cmH2O. In a median follow-up time of 9.2 months, Crude mortality is 8.365% in the high CVP group compared to 1.929% in the low CVP group (p<0.0001). In multivariate analysis, CVP remained the independent predictor of survival.

CONCLUSIONS

High CVP is associated with AKI , and it is independently related to all-cause mortality in patients underwent cardiovascular surgery with cardiopulmonary bypass.

Multiple Genetic Associations with Irish Wolfhound Dilated Cardiomyopathy

Cardiac disease is a leading cause of morbidity and mortality in dogs and humans, with dilated cardiomyopathy being a large contributor to this. The Irish Wolfhound (IWH) is one of the most commonly affected breeds and one of the few breeds with genetic loci associated with the disease. Mutations in more than 50 genes are associated with human dilated cardiomyopathy (DCM), yet very few are also associated with canine DCM. Furthermore, none of the identified canine loci explain many cases of the disease and previous work has indicated that genotypes at multiple loci may act together to influence disease development. In this study, loci previously associated with DCM in IWH were tested for associations in a new cohort both individually and in combination. We have identified loci significantly associated with the disease individually, but no genotypes individually or in pairs conferred a significantly greater risk of developing DCM than the population risk. However combining three loci together did result in the identification of a genotype which conferred a greater risk of disease than the overall population risk. This study suggests multiple rather than individual genetic factors, cooperating to influence DCM risk in IWH.

Left ventricular ejection fraction and mortality in patients with ST-elevation myocardial infarction and bundle branch block

BACKGROUND

The aim of our study is to assess the effect of bundle branch block (BBB) on mortality and left ventricular ejection fraction (LVEF) in ST-elevation myocardial infarction (STEMI) patients treated in the current era of percutaneous reperfusion therapy.

PATIENTS AND METHODS

In this retrospective cohort study, a total of 1123 STEMI patients treated in the University Medical Center Groningen from January 2011 until May 2013 were included. The follow-up duration was 2-4 years. Transthoracic echocardiography was performed within 2 weeks after STEMI.

RESULTS

In total, 23 (2.0%) patients presented with left BBB and 49 (4.4%) patients presented with right BBB. Two-year mortality after STEMI was 25.0% (n=18) in patients with BBB and 9.2% (n=97, P<0.001) in patients without BBB. Patients with BBB had more frequently a severely reduced LVEF (<30%) [20.0% (n=6) compared with 4.2% (n=21), P=0.002] and less frequently a normal LVEF [16.7% (n=5) compared with 35.7% (n=179), P=0.046]. After multivariable analysis, BBB did not remain an independent predictor of mortality, but was an independent predictor of reduced LVEF.

CONCLUSION

The presence of a BBB was an independent predictor of a reduced LVEF. However, we found no effect of BBB on 2-year mortality in the current era of percutaneous reperfusion therapy.

Outcomes and predictors of recovery in acute-onset cardiomyopathy: A single-center experience of patients undergoing endomyocardial biopsy for new heart failure

BACKGROUND

About one-third of patients with unexplained acute-onset heart failure (HF) recover left ventricular (LV) function; however, characterization of these patients in the setting of contemporary HF therapies is limited. We aim to describe baseline characteristics and predictors of recovery in patients with acute-onset cardiomyopathy.

METHODS

We previously described 851 patients with unexplained HF undergoing endomyocardial biopsy. In this study, 235 patients with acute-onset HF were further retrospectively examined.

RESULTS

Follow-up LV ejection fraction (LVEF) was available for 138 patients. At 1 year, 48 of 138 (33%) had LVEF recovery (follow-up LVEF ≥50%), and 90 of 138 (65%) had incomplete or lack of recovery. Higher cardiac index (P=.019), smaller LV diastolic diameter (P=.002), and lack of an intraventricular conduction delay (IVCD) (P=.002) were associated with LVEF recovery. IVCD (P=.001) and myocarditis (P=.016) were independent predictors of the composite end point of death, LV assist device placement, and/or transplant at 1 year. Those with an IVCD had a significantly lower 1-year survival than those without (P=.007).

CONCLUSIONS

Patients with a smaller LV end-diastolic diameter, higher cardiac index, and lack of IVCD at presentation for acute-onset HF were more likely to have LVEF recovery. IVCD was a poor prognostic marker in all patients presenting with acute cardiomyopathy.

Lessons Learned and Insights Gained in the Design, Analysis, and Outcomes of the COMPANION Trial

COMPANION (Comparison of Medical Therapy, Pacing and Defibrillation in Heart Failure), the first cardiac resynchronization therapy (CRT)-heart failure mortality and morbidity controlled clinical trial planned, conducted, and reported, was a randomized, 3-arm study that compared CRT delivered by a biventricular pacemaker (CRT-P) or a CRT defibrillator device (CRT-D) with optimal pharmacological therapy alone. The patient population had advanced chronic heart failure with QRS interval prolongation ≥120 ms and reduced left ventricular ejection fraction (heart failure with reduced ejection fraction). COMPANION had a composite hospitalization and mortality endpoint as the primary outcome measure but was also powered for mortality as the first secondary endpoint. The conduct of COMPANION was challenged by important issues that arose during the trial, the most important of which was U.S. Food and Drug Administration approval of CRT devices. Along with other challenges, this issue was appropriately dealt with by the Steering Committee and the Data and Safety Monitoring Committee and did not negatively affect trial results or conclusions. The authors report here updated analyses from the study, which are consistent with previously published results indicating that CRT-P or CRT-D has favorable effects on heart failure morbidity and mortality in a patient population "precision" selected by the surrogate marker of increased QRS interval duration. New analyses indicate that increasing the number of classes of neurohormonal inhibitor concurrent therapy has a positive effect on CRT mortality reduction. Hypothesis-generating new findings are that in patients receiving beta-blocker therapy, the mortality reduction advantage of CRT-D versus CRT-P may be minimized or eliminated and that there may be adverse effects of CRT-D defibrillator shocks on pump failure-related outcomes.

Indications for pacemakers, implantable cardioverter-defibrillator and cardiac resynchronization devices

Implantable cardiac devices are important management tools for patients with heart rhythm disorders and heart failure. In this article, the current implantable cardiac rhythm devices are described in their evolution. The current indications and contraindications for these cardiac rhythm devices are reviewed.

Prognostic role of cardiac power index in ambulatory patients with advanced heart failure

BACKGROUND

Cardiac pump function is often quantified by left ventricular ejection fraction by various imaging modalities. As the heart is commonly conceptualized as a hydraulic pump, cardiac power describes the hydraulic function of the heart. We aim to describe the prognostic value of resting cardiac power index (CPI) in ambulatory patients with advanced heart failure.

METHODS AND RESULTS

We calculated CPI in 495 sequential ambulatory patients with advanced heart failure who underwent invasive haemodynamic assessment with longitudinal follow-up of adverse outcomes (all-cause mortality, cardiac transplantation, or ventricular assist device placement). The median CPI was 0.44 W/m(2) (interquartile range 0.37, 0.52). Over a median of 3.3 years, there were 117 deaths, 104 transplants, and 20 ventricular assist device placements in our cohort. Diminished CPI (<0.44 W/m(2) ) was associated with increased adverse outcomes [hazard ratio (HR) 2.4, 95% confidence interval (CI) 1.8-3.1, P < 0.0001). The prognostic value of CPI remained significant after adjustment for age, gender, pulmonary capillary wedge pressure, cardiac index, pulmonary vascular resistance, left ventricular ejection fraction, and creatinine [HR 1.5, 95% CI 1.03-2.3, P = 0.04). Furthermore, CPI can risk stratify independently of peak oxygen consumption (HR 2.2, 95% CI 1.4-3.4, P = 0.0003).

CONCLUSION

Resting cardiac power index provides independent and incremental prediction in adverse outcomes beyond traditional haemodynamic and cardio-renal risk factors.

Adrenergic receptor genotype influences heart failure severity and β-blocker response in children with dilated cardiomyopathy

BACKGROUND

Adrenergic receptor (ADR) genotypes are associated with heart failure (HF) and β-blocker response in adults. We assessed the influence of ADR genotypes in children with dilated cardiomyopathy (DCM).

METHODS

Ninety-one children with advanced DCM and 44 with stable DCM were genotyped for three ADR genotypes associated with HF risk in adults: α2cdel322-325, β1Arg389, and β2Arg16. Data were analyzed by genotype and β-blocker use. Mean age at enrollment was 8.5 y.

RESULTS

One-year event-free survival was 51% in advanced and 80% in stable DCM. High-risk genotypes were associated with higher left ventricular (LV) filling pressures, higher systemic and pulmonary vascular resistance, greater decline in LV ejection fraction (P < 0.05), and a higher frequency of mechanical circulatory support while awaiting transplant (P = 0.05). While β-blockers did not reduce HF severity in the overall cohort, in the subset with multiple high-risk genotypes, those receiving β-blockers showed better preservation of cardiac function and hemodynamics compared with those not receiving β-blockers (interaction P < 0.05).

CONCLUSION

Our study identifies genetic risk markers that may help in the identification of patients at risk for developing decompensated HF and who may benefit from early institution of β-blocker therapy before progression to decompensated HF.

Relationship of decreased accumulation of (99m)Tc-tetrofosmin on myocardial single-photon emission computed tomography images between QRS duration in dilated cardiomyopathy patient with left bundle branch block

PURPOSE

This study aimed to clarify the relationship between severity of conduction delay in the left ventricle and myocardial uptake of (99m)Tc-tetrofosmin (TF) in dilated cardiomyopathy (DCM) patients with left bundle branch block (LBBB).

METHODS AND RESULTS

Thirty-two DCM patients with LBBB underwent electrocardiography and (99m)Tc-TF myocardial single-photon emission computed tomography (SPECT). SPECT images were acquired at 30 min (early images) and 3 h (late images) after injection. We calculated the total defect score (TDS) using a 20-segment model with a 5-point scoring system. The TDS in early and late images was defined as the summed early score (SES) and summed late score (SLS), respectively. On early images, 29 of 32 patients (91%) had decreased tracer uptake in the septum. All patients showed a decreased tracer uptake in the septum on late images. A significant correlation was observed between TDS (both SES and SLS) and QRS duration, with SLS showing an excellent correlation (SES: r = 0.554, P < 0.001; SLS: r = 0.779, P < 0.0001).

CONCLUSIONS

These findings suggest that in DCM patients with LBBB, hypoperfusion and myocardial damage in the septum might occur in accordance with an increase in the QRS duration.

Gremlin-1 identifies fibrosis and predicts adverse outcome in patients with heart failure undergoing endomyocardial biopsy

BACKGROUND

Gremlin-1 (Grem1), an antagonist of bone morphogenetic proteins, is involved in fibrotic tissue formation in kidney and lung. The impact of myocardial Grem1 expression is unknown. We investigated the prognostic value of Grem1 expression in 214 consecutive patients with nonischemic heart failure (HF) undergoing endomyocardial biopsy.

METHODS

In all patients, the following risk factors were assessed: Grem1 expression (semiquantitative score scheme ranging from 1 to 4), presence of inflammatory markers, detection of viral genome, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), New York Heart Association functional class (NYHA), troponin I, and B-type natriuretic peptide. Degree of myocardial fibrosis was defined as an index. Study end point was a combination of all-cause death and HF-related rehospitalization within 3 years of follow-up.

RESULTS

Grem1 expression significantly correlated with the degree of myocardial fibrosis (correlation coefficient r = 0.619; P < .0001). Patients with the highest Grem1 expression (score 4) showed the most severely impaired LVEF and highest LVEDD (P < .0001 and P = .030, respectively, for comparison of semiquantitative scores). During follow-up, 33 patients (15.4%) reached the study end point. Grem1 expression and NYHA ≥II were independent predictors of the end point (Grem1: hazard ratio [HR] 7.5, 95% confidence interval [CI] 1.8-32.2; P = .006; NYHA ≥II: HR 2.0, 95% CI 1.0-4.1; P = .048).

CONCLUSIONS

Grem1 correlates with the degree of myocardial fibrosis and left ventricular dysfunction and is an independent predictor of adverse outcome in patients with nonischemic HF.

The prognostic significance of central hemodynamics in patients with cardiac amyloidosis

BACKGROUND

The diagnosis of cardiac amyloidosis often requires a right heart catheterization with an endomyocardial biopsy. Although the central hemodynamics of the three main types of cardiac amyloidosis (AL, ATTRm, ATTRwt) have previously been described, the prognostic significance of these variables have not been fully explored.

OBJECTIVE

To compare the right heart catheterization variables between the three sub-groups of AL, ATTRm and ATTRwt, and describe if any of these variables are of prognostic significance.

METHODS

We conducted a retrospective cohort analysis of patients with biopsy confirmed cardiac amyloidosis between 1997 and 2011. Central hemodynamics as well as baseline clinical and laboratory characteristics were collected at the time of diagnosis. The prognostic significance of the central hemodynamics was evaluated. The internal review board of our institution approved the study.

RESULTS

Patients with ATTR and AL cardiac amyloidosis had similar central hemodynamic profiles of high filling pressures and low cardiac output with the exception of ATTR having higher pulmonary artery systolic pressure and pulmonary vascular resistance. Right atrial pressure (RAP), pulmonary artery diastolic pressure, pulmonary capillary wedge pressure and pulmonary artery saturation were individual predictors of death or heart transplantation (p < 0.05). However, when each was added to RAP they did not increase the predictive value compared to RAP alone.

CONCLUSION

The central hemodynamics of ATTR and AL amyloidosis were found to be similar and RAP emerged as the main predictor of transplant-free survival.

Normality index of ventricular contraction based on a statistical model from FADS

Radionuclide-based imaging is an alternative to evaluate ventricular function and synchrony and may be used as a tool for the identification of patients that could benefit from cardiac resynchronization therapy (CRT). In a previous work, we used Factor Analysis of Dynamic Structures (FADS) to analyze the contribution and spatial distribution of the 3 most significant factors (3-MSF) present in a dynamic series of equilibrium radionuclide angiography images. In this work, a probability density function model of the 3-MSF extracted from FADS for a control group is presented; also an index, based on the likelihood between the control group's contraction model and a sample of normal subjects is proposed. This normality index was compared with those computed for two cardiopathic populations, satisfying the clinical criteria to be considered as candidates for a CRT. The proposed normality index provides a measure, consistent with the phase analysis currently used in clinical environment, sensitive enough to show contraction differences between normal and abnormal groups, which suggests that it can be related to the degree of severity in the ventricular contraction dyssynchrony, and therefore shows promise as a follow-up procedure for patients under CRT.

Efficacy of pimobendan in the prevention of congestive heart failure or sudden death in Doberman Pinschers with preclinical dilated cardiomyopathy (the PROTECT Study)

BACKGROUND

The benefit of pimobendan in delaying the progression of preclinical dilated cardiomyopathy (DCM) in Dobermans is not reported.

HYPOTHESIS

That chronic oral administration of pimobendan to Dobermans with preclinical DCM will delay the onset of CHF or sudden death and improve survival.

ANIMALS

Seventy-six client-owned Dobermans recruited at 10 centers in the UK and North America.

METHODS

The trial was a randomized, blinded, placebo-controlled, parallel group multicenter study. Dogs were allocated in a 1:1 ratio to receive pimobendan (Vetmedin capsules) or visually identical placebo. The composite primary endpoint was prospectively defined as either onset of CHF or sudden death. Time to death from all causes was a secondary endpoint.

RESULTS

The proportion of dogs reaching the primary endpoint was not significantly different between groups (P = .1). The median time to the primary endpoint (onset of CHF or sudden death) was significantly longer in the pimobendan (718 days, IQR 441-1152 days) versus the placebo group (441 days, IQR 151-641 days) (log-rank P = 0.0088). The median survival time was significantly longer in the pimobendan (623 days, IQR 491-1531 days) versus the placebo group (466 days, IQR 236-710 days) (log-rank P = .034).

CONCLUSION AND CLINICAL IMPORTANCE

The administration of pimobendan to Dobermans with preclinical DCM prolongs the time to the onset of clinical signs and extends survival. Treatment of dogs in the preclinical phase of this common cardiovascular disorder with pimobendan can lead to improved outcome.

Pacing polarity and left ventricular mechanical activation sequence in cardiac resynchronization therapy

OBJECTIVE

The aim of this study is to evaluate the relationship between polarity of left ventricular (LV) pacing and the resultant regional, global, and transmural mechanical sequence of contraction.

BACKGROUND

Cardiac resynchronization therapy (CRT) is widely utilized in patients with drug refractory congestive heart failure with systolic dysfunction (EF <35 %) and intraventricular conduction delay (QRS duration >120 ms). However, little is known about polarity of pacing stimulation and the resultant differences in LV mechanics.

METHODS

The polarity of pacing was altered sequentially in 20 patients (73 ± 13, 16 males) with preexisting biventricular devices with potential choice of multiple vectors for pacing stimulation. Initial unipolar or extended bipolar configurations were switched to bipolar configuration or vice versa, and echocardiographic images were acquired for off-line analysis. Regional and global LV longitudinal and radial mechanics were assessed selectively from the subendocardial and subepicardial regions with 2D speckle-tracking echocardiography. Left ventricular capture by each vector configuration was confirmed by local lead capture and appropriate QRS alteration.

RESULTS

Unipolar pacing resulted in increased dispersion of LV regional endocardial strains with a higher base-to-apex gradients of longitudinal shortening strains (P < 0.05). LV longitudinal shortening strain magnitude was higher at LV base with bipolar stimulation in comparison with unipolar stimulation (-10.5 ± 10.5 vs. -4.2 ± 6.3, P = 0.02).

CONCLUSION

There is a difference in the mechanical activation sequence of the LV between unipolar vs. bipolar pacing stimulation. This may have important implications for CRT.

Sudden cardiac death risk stratification in patients with heart failure

The multiplicity of mechanisms contributing to arrhythmogenesis in patients with heart failure carries obvious implications for risk stratification. If patients having the propensity to develop arrhythmias by these different mechanisms are to be identified, tests must be devised that reveal the substrates or other factors that relate to each mechanism. In the absence of this, efforts to risk stratify patients are likely to be neither cost-effective nor accurate. This article reviews the current knowledge base of risk stratification for sudden death in patients with heart failure, while acknowledging several limitations in the studies examined.

Cardiomyocyte hypertrophy, oncosis, and autophagic vacuolization predict mortality in idiopathic dilated cardiomyopathy with advanced heart failure

OBJECTIVES

The aim of this study was to identify the remodeling parameters cardiomyocyte (CM) damage or death, hypertrophy, and fibrosis that may be linked to outcomes in patients with advanced heart failure (HF) in an effort to understand the pathogenic mechanisms of HF that may support newer therapeutic modalities.

BACKGROUND

There are controversial results on the influence of fibrosis, CM hypertrophy, and apoptosis on outcomes in patients with HF; other modalities of cell damage have been poorly investigated.

METHODS

In endomyocardial biopsy specimens from 100 patients with idiopathic dilated cardiomyopathy and advanced HF, CM diameter and the extent of fibrosis were determined by morphometry. The proportion of CMs with evidence of apoptosis, autophagic vacuolization (AuV), and oncosis was investigated by immunohistochemical methods and by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling. Those parameters were correlated with mortality in 3 years of follow-up by univariate analysis and with multivariate models incorporating the clinical variables more relevant to the prediction of outcomes.

RESULTS

CM AuV occurred in 28 patients (0.013 ± 0.012%) and oncosis in 41 (0.109 ± 0.139%). Nineteen patients showed both markers. Apoptotic CM nuclei were observed in 3 patients. In univariate analysis, CM diameter and AuV, either alone or associated with oncosis, were predictors of mortality. In multivariate analysis, CM diameter (hazard ratio: 1.37; 95% confidence interval: 1.12 to 1.68; p = 0.002) and simultaneous presence in the same endomyocardial biopsy specimen of AuV and oncosis (hazard ratio: 2.82; 95% confidence interval: 1.12 to 7.13; p = 0.028) were independent predictors of mortality.

CONCLUSIONS

CM hypertrophy and AuV, especially in association with oncosis, are predictors of outcome in patients with idiopathic dilated cardiomyopathy and severe HF.

Assessment of cardiac dynamics during stress echocardiography by the peak power output-to-left ventricular mass ratio

Peak cardiac power-to-mass and peak mass-to-power are variables that couple cardiac power output with left ventricular (LV) mass at peak exercise or during maximal inotropic stimulation. Quantitative stress echocardiography enables the calculation of power output according to the formula: 133 × 10–6 × stroke volume per second (ml) × mean blood pressure (BP; mmHg) × heart rate. Power-to-mass may be calculated as LV power output per 100 g of LV mass: 100 g × LV power output divided by LV mass (W/100 g). Conversely, mass-to-power may be estimated by dividing LV mass index by LV power output (g/m2/W). With a little rearrangement of the formulas we can write: power-to-mass (W/100 g) = 0.222 × cardiac output (l/min) × mean BP (mmHg)/LV mass (g) and mass-to-power (g/m2/W) = LV mass index/0.00222 × cardiac output (l/min) × mean BP (mmHg). These parameters reflect the energy delivery of ventricular myocardium with respect to potential energy that is stored in LV mass. The assessment of peak power-to-mass and peak mass-to-power indices may be useful to distinguish compensatory versus maladaptive remodeling in patients with LV dysfunction. When the integrity of myocardial structure is compromised, a disproportion becomes apparent between maximal cardiac power output and LV mass and this leads to either a reduction of peak power-to-mass or an increase of peak mass-to-power. Preliminary reports have demonstrated the usefulness and the prognostic value of peak power-to-mass and peak mass-to-power in patients with LV systolic dysfunction and coronary artery disease.

Six-minute walk distance predicts 30-day readmission in hospitalized heart failure patients

BACKGROUND AND AIMS

Identification of patients with heart failure (HF) at high risk of hospital readmission is critical to refine processes for reducing readmission rates. We hypothesized that patients with higher 6-min walk (6MW) distance at the time of hospital discharge are at low risk for early readmission.

METHODS

We prospectively enrolled 265 patients admitted with HF and left ventricular systolic dysfunction. 6MW testing was administered prior to discharge. Multivariate logistic regression analysis was performed to determine the relationship between 6MW distance and 30-day readmission, stratifying by ≤400 m and >400 m.

RESULTS

Two hundred ten patients underwent 6MW testing prior to discharge. Patients with 6MW >400 m had a 30-day readmission rate of 15.9%, whereas patients with 6MW ≤400 m had a 30-day readmission rate of 30.3% (p = 0.016). Patients requiring readmission within 30 days had a median 6MW of 30 m, whereas patients not requiring readmission at 30 days walked 338 m (p = 0.012). 6MW distance predicted freedom from readmission at 30 days (OR: 0.435, 95% CI 0.21-0.9, p = 0.025). Other independent predictors of 30-day readmission included history of gout (0.117, 0.021-0.637, p = 0.013), use of angiotensin-converting enzyme inhibitor or accepted alternative (0.372, 0.169-0.820, p = 0.014) and blood urea nitrogen level (1.019, 1.003-1.035, p = 0.020).

CONCLUSIONS

Low 6MW distance predicts early hospital readmission in patients with HF. Programs seeking to produce systems that are effective in reducing early hospital readmission may desire to incorporate 6MW testing during HF hospital care.

Sociology meets genetics: sociogenetic implications for future management of hypertension and heart failure

Hypertension and heart failure contribute significantly to morbidity and mortality in the United States. Suboptimal control of these disease processes is multifactorial and involves poorly understood mechanisms affected by the environment (socioeconomic factors) and genetics (cell biology). Dietary sodium is an illustrative case. Although physicians intuitively accept that sodium affects renal and cardiovascular physiology, the complex overlay of genetics, environment, and culture is not practically addressed to make a meaningful difference in patient care. Optimal control of hypertension and heart failure will require a personalized care plan for each patient that includes lifestyle changes and carefully selected pharmacotherapy and also accounts for sociogenetic factors that affect each patient's life and thus his or her disease process. Physicians' cultural biases and perceptions also must be factored into this complex patient care equation.